Special Education Inquiry

You have entered the online inquiry process for Clinton County RESA's Special Education.

This form is to refer individuals, 3 to 26, for possible special education services. When a referral is received, the parent or legal guardian will be contacted in order to discuss the referral and a possible evaluation for special education services. To place a referral for a child birth up to age 3, visit www.1800EarlyOn.org.

If you have questions about our online inquiry process, please feel free to contact us at eoreferral@edzone.net. Service is also available for the deaf or hard of hearing by calling the Michigan Relay Center at 1-800-649-3777 for additional assistance.

Clinton County RESA serves students and families living in the following local school districts: Bath Community Schools, DeWitt Public Schools, Fowler Public Schools, Ovid-Elsie Area Schools, Pewamo-Westphalia Community Schools, and St. Johns Public Schools.

The referral can also be made by phone by calling our local referral line at: (989)224-5678

Build Up Michigan

Build Up Logo

Build Up helps parents and their children, ages 3 through 5, get additional educational support as they begin and continue to learn the skills needed to enter kindergarten.

Inquiry Form

Does the parent or guardian need an interpreter?
¿El padre o tutor necesita un intérprete?
Yes 
No 

Child's Information

Child's Name:


Date of Birth *:
If your child is close to turning age 3, they may be referred to the local special education program.
In order to send this inquiry on to the appropriate agency, we need an address. If the child and/or parent does not have a permanent address, please call 1-800-327-5966 to complete this inquiry. We can not use P.O. Box numbers.
Address where the child is currently living:




County where child currently resides*:
School district where child currently resides*:
Gender:
Male 
Female 
What race or ethnicity is this child?
(check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Unknown
White
Was the child premature?
Yes 
No 
Is the child a twin or triplet?
Yes 
No 
Does the child have an IFSP (Individualized Family Service Plan) or IEP (Individualized Education Plan)?
Yes
No
Unsure
Other health or developmental concerns?
(check all that apply)
Behavior
Communication
Health or medical concerns
Hearing
Lead exposure
Physical movement: for example, use of hands, crawling, or walking
Vision
Other:
Please give a detailed description of the concern/reason for inquiry:
Also provide any medical background, including any diagnosis or evaluations.

Parent/Legal Guardian Information

Guardianship:
Birth Parent
Adoptive Parent
Foster Parent
Legal Guardian
Other:
Parent's Name

Second Parent's Name

Providing an email address will ensure communication with the family about Build Up Michigan.
Please check if the parent/guardian DOES NOT have an email address.
Primary Phone*:
- - Ext.
Alternate Phone:
- - Ext.
Is it ok for us to text the parent/guardian?
Yes 
No 
Parent's Mailing Address
Click if this address is the same as where the child is currently living.






Inquiry Source Contact Information

Your relation to the child:
Parent
Grandparent
Sibling
Aunt or Uncle
Friend
Social Worker
Physician
Teacher
Childcare
Other:
Your Name

Your Phone*:
- - Ext.
Your Fax:
- -
Your Address




Does the family know that you are submitting this inquiry?
Yes 
No 
Is it ok for the family to know that you are submitting this inquiry?
Yes 
No 
How did you find out about us?
Pediatrician
Hospital
Department of Health and Human Services
Teacher/Education Professional
Childcare Provider
Family Member
Web Site
Home Visitor
Other